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NURSING CARE FOR CHILDREN WITH RESPIRATORY PROBLEMS RESPIRATORY SYSTEM Respiratory rates are higher in children Airway

irway diameter is smaller in children which increases the potential for obstruction Mucous membranes of the airways are highly vascular and are susceptible to trauma, edema, and spasm Surfactant is lacking in preterm infants, which contributes to respiratory distress syndrome Chest wall retractions are common in infants with respiratory problems because the chest wall is supple

DEVELOPMENT: The laryngotracheal groove appears 2 4 weeks of gestation The trachea and the esophagus originates as one hollow tube; gradually, by 4 weeks of gestation, a septum forms to completely separate them The diaphragm forms at the 7th week of fetal life separating the chest from the abdominal cavity Alveoli and capillaries, which are necessary for gas exchange in the human body are formed between 24 and 28 weeks of gestation At the 24th week, the formed alveolar cells begin to produce surfactant. Surfactant is composed of lecithin and sphingomyelin At 35 weeks of gestation, the lecithin component is twice that of the sphingomyelin component. RESPIRATORY TRACT IN CHILDREN The ribs and the diaphragm allow for inspiration of air Air enters the body through the nares The mucous membranes and cilia that line the respiratory tract warm, moisten, and filter the air as it passes to the pharynx The pharynx contains the tonsils which assist in infection control The larynx at the upper end of the trachea contains the epiglottis, the glottis, and the vocal cords which prevent food and fluids from entering the trachea and allow voice sounds. The trachea is encircled by smooth muscle and cartilage to maintain patency and carries the air to the bronchi and to the smaller bronchioles. The bronchioles continue to divide and lead to small, thin air sacs, the alveoli that are kept open on inspitation by the air contained in them.. During expiration, when the air sacs collapse, surfactant prevents the walls from sticking together, allowing for reinflation. Gas occurs in the alveoli by diffusion to the bloodstream VENTILATION the process of breathing air into and out of the lungs, affected by the following elements that interact: Intercostal muscles, diaphragm, ribs allow chest expansion and contraction. Expansion of the chest lowers pressure in the chest cavity, and air flows from the higher pressure of the atmosphere into the lower pressure of the chest cavity. Brain the vagus nerve and the respiratory centers in the medulla of the brain regulate rythmic respiratory movements. Signals sent to the respiratory center will increase or decrease the respiratory rates. Chemoreceptors these sensors respond to changes in the oxygen saturation of the blood by sending a signal to the pons in the brainstem, which is stimulated to increase respirations when the oxygen saturation is low.

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RESPIRATORY DISTRESS SYNDROME (RDS)

- also known as hyaline membrane disease - a complex respiratory disease primarily caused by a deficiency of surfactant which leads to higher surface tension at the alveoli which interferes with normal exchange of oxygen and carbon dioxide. - this is seen almost exclusively in preterm infants - there is a deficient synthesis or release of surfactant - MANIFESTATIONS: tachypnea (up to 80 120 breaths/minute; dyspnea; pronounced intercostal and/or substernal retractions due to increased ribcage compliance and decreased lung compliance; inspiratory crackles; audible expiratory grunting; nasal flaring; cyanosis or pallor - THERAPEUTIC MANAGEMENT: 1. administration of exogenous surfactant via endotracheal tube 2. oxygen therapy via oxygen hood NURSING DIAGNOSES: 1. Ineffective breathing pattern related to surfactant deficiency, alveolar instability, and pulmonary immaturity 2. Impaired gas exchange related to immature alveolar structures 3. Impaired gas exchange related to inability to maintain lung expansion PLANNING: 1. Newborn will exhibit optimum air exchange and oxygenation 2. Newborn will exhibit desired respiratory function IMPLEMENTATION: 1. Suction secretions when necessary 2. Positioning 3. Inspection of the skin 4. Mouth care

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MECONIUM ASPIRATION SYNDROME (MAS)

- aspiration of amniotic fluid containing meconium into fetal or newborn trachea in utero or at first breath - typically occurs when the fetus is stressed during labor, especially when the infant is past its due date - stress during labor can cause increased movement of the infant's intestines and relaxation of the anal sphincter, causing meconium to pass into the surrounding amniotic fluid - meconium -causes mechanical blockage of the airway which results in atelectasis - causes chemical pneumonitis: enzymes, bile salts, fats in meconium irritate the airways which causes alveolar collapse and cell necrosis - causes surfactant dysfunction: constituents of meconium especially fatty acids have a higher minimal surface tension than surfactant and strip it from the alveolar surface, resulting in atelectasis MANIFESTATIONS: meconium stained at birth; tachypnea; hypoxia; cyanosis; hyperventilation; intercostal retractions MANAGEMENT: monitoring for intrauterine fetal distress amnioinfusion suctioning upon delivery of the fetal head endotracheal suctioning supportive care with warmth, oxygen and energy-conserving plans of care NURSING CARE: during labor, continuously monitor the fetus for signs and symptoms of distress immediately inspect any fluid passed with rupture of the membranes assist with immediate endotracheal suctioning as indicated monitor lung status closely including breath sounds and respiratory rate and character frequently assess vital signs administer oxygen as ordered provide the family with emotional support and guidance 1. APNEA OF PREMATURITY - lapse of spontaneous breathing for 20 seconds or longer, accompanied by hypoxia or bradycardia - exact cause is unknown but is thought to be due to immature CNS - obstructive apnea - may occur when the infant's neck is hyperflexed or conversely, hyperextended. It may also occur due to low pharyngeal muscle tone or to inflammation of the soft tissues, which can block the flow of air though the pharynx and vocal cords - central apnea - occurs when there is a lack of respiratory effort. This may result from central nervous system immaturity, or from the effects of medications or illness - mixed apnea combination of both types - MANIFESTATIONS: persistent apneic spells - MANAGEMENT: - administration of methylxanthines (theophylline and caffeine) to stimulate breathing and reduce apnea - cardiac and respiratory monitoring until no episodes of apnea for 5 7 days - respiratory support - tactile stimulation by touching the skin of the infant may stop apneic episode by raising the infant's level of alertness - supplementary oxygen which can diminish the frequency of AOP; helps maintain adequate oxygenation during short periods of apnea - CPAP continuous positive airway pressure - endotracheal intubation and mechanical ventilation NURSING CARE: assess infant's color, perfusion, respiratory rate, heart rate and positioning document frequency and severity of episodes as well as the type and amount of stimulation required to interrupt the event ensure bag and mask set ups with oxygen available at newborn's bedside observe careful positioning; avoid flexion or hyperextension of newborn's neck 1. BRONCHOPULMONARY DYSPLASIA - a.k.a. Chronic lung disease - a pathologic process that develops in neonates treated with positive pressure ventilation and oxygen for primary lung problems such as RDS; immature alveoli and respiratory tract - characterized by a fibrosis or thickening, inflammation and scarring of alveolar walls and the bronchiolar epithelium causing edema; respiratory cilia are also paralyzed by high oxygen concentrations - regardless of the concentration of inspired oxygen, if it is given over a long period of time, BPD may develop - closely related to Wilson-Mikity Syndrome (Pulmonary Dysmaturity): seen in infants below 1500 grams - MANIFESTATIONS: - episodic bronchospasm with wheezing - retractions - cyanosis - clubbing of fingers a sign of chronic hypoxia - irritability TREATMENT: PREVENTIVE AND SUPPORTIVE - preventing prematurity - careful management of RDS which includes low ventilator pressures and careful use of oxygen - once diagnosed, goal of therapy is to reduce inflammation of the airway and to wean the infant from the mechanical ventilator NURSING CARE - prevent further lung damage - oxygen therapy as ordered

- provide developmental care and enhancement - provide for opportunities for additional rest during feedings - assess for susceptibility to upper respiratory tract infections 1. CHOANAL ATRESIA the most common congenital malformation of the nose. a congenital obstruction of the posterior nares at the entrance to the nasopharynx the obstruction is usually caused by a bony growth may be unilateral or bilateral MANIFESTATIONS: - unilateral: mucoid discharge from only one nostril - bilateral: apnea and cyanosis at birth and may require resuscitation in order to prevent asphyxia TREATMENT: relief of bilateral atresia as early as possible after birth - transnasal puncture if a membranous obstruction is present - surgery if bony obstruction is present NURSING CARE - directed at keeping the nostrils clean and preventing upper respiratory tract infections 1. DIAPHRAGMATIC HERNIA - a relatively rare condition caused by abnormal embryonic development - occurs when there is a failure of the pleuroperitoneal canal in the posterior lateral segment of the diaphragm to close completely at about the eighth week of embryonic development - there may be a slight herniation of abdominal organs or there may be an extreme protrusion of abdominal contents into the thoracic cavity at birth - in severe malformations, the intestines and stomach, liver spleen and kidneys may press the lungs and heart from normal positions - the lung on the affected side, is compressed and often hypoplastic - MANIFESTATIONS: - severe respiratory difficulty: tachypnea, dyspnea, retractions, cyanosis - the affected side of the chest does not expand as does the unaffected side - the abdomen is generally small and scaphoid in contour - chest appears relatively large TREATMENT: - Surgery is done to replace the abdominal organs into the proper position and repair the opening in the diaphragm. - consists of replacing the abdominal viscera in the abdominal cavity and repairing the defect NURSING CARE: - Preop: place infant on affected side and in semi-fowler's position - keep the infant as quiet as possible - NGT with intermittent suction is begun as soon as the diagnosis is made in order to reduce the amount of air in the GI tract thus reducing respiratory difficulty 1. SUDDEN INFANT DEATH SYNDROME (SIDS) - crib death - sudden, unexpected death of an apparently healthy infant between 2 weeks and 1 year of age, for which a routine autopsy fails to identify the cause - peak incidence is between 2 and 4 months of age - etiology unknown - CLINICAL FEATURES: - death occurs during sleep - the infant does not cry or make other sounds of distress RISK REDUCTION: - positioning on the back - second-hand smoke reduction - co-sleeping - providing for a safe sleeping area NURSING RESPONSIBILITY - convey important facts to grieving parents: - that the infant died of a disease entity called sudden infant death syndrome - that currently the disease cannot be predicted or prevented - that they are not responsible for the child's death 1. ACTUE NASOPHARYNGITIS (Common Cold) - the most common repiratory infeciton in infants and children - in addition to the nasopharynx, the accessory paranasal sinuses and the middle ear are generally involved - this infection can spread quickly and serious complications can result - caused by rhinoviruses, adenovirus, influenza virus and parainfluenza virus - spread by coughing, sneezing, or direct contact - characterized by edema of the membranes of the upper respiratory tract; production of mucus that is at first profuse and thin and that later becomes thick and purulent - MANIFESTATIONS: (more severe in infancy) - onset of fever from 39 40o C which lasts from a few hours to 3 days - irritability and restlessness

- presence of nasal discharges - difficulty in feeding which leads to dehydration - in older children, manifestations include irritation and dryness of the mucous membranes of the nose; sneezing; coughing; slight fever; headache; weakness; mouth-breathing - TREATMENT: no cure; symptomatic treatment (antipyretics, antitussives, decongestants - NURSING RESPONSIBILITIES: - parent education on home management (most important) - promote rest and isolation from sources of further infection - provide adequate fluids and nutrition - clear airways - management of fever - skin care - older children should be taught the proper way to remove nasal secretions - prevent and assess for indications of complications 2. ACUTE BRONCHIOLITIS - a common viral disease of the lower respiratory tract of infants resulting from inflammatory obstruction at the bronchiolar level - usually occurs between the ages of 2 and 12 months with the peak incidence at 6 months of age and is rare after 2 years - usually caused by RSV (respiratory syncitial virus); may also be caused by some adenoviruses, parainfluenza viruses and mycoplasma pneumoniae - MANIFESTATIONS: - respiratory distress characterized by paroxysmal wheezy cough, dyspnea, irritability; increased respiratory rate; may have low-grade fever; tachypnea; nasal flaring; intercostal retractions; air hunger and cyanosis; wheezing upon auscultation because of the turbulence of airflow through the partially obstructed air passages; as the disease progresses, wheezing disappears; chest is barrel shaped d/t overinflation of the lungs TREATMENT: symptomatic NURSING CARE: - high-humidity atmosphere and oxygen - adequate hydration - rest - positioning - parental support 1. ASPIRATION OF FOREIGN BODIES (FB) - occurs mostly in infants and toddlers between the ages 6 months and 3 years - the act of reflex coughing may expel some objects but others may be retained in the respiratory tract resulting in either immediate or delayed clinical manifestations - pathophysiologic effects are dependent on the composition, anatomic location, and degree of air passage obstruction caused by the foreign object -NURSING CARE: - assist in prompt removal of foreign body under direct vision by laryngoscopy or bronchoscopy (prevents local tissue inflammation) - parental education on signs of airway obstruction e.g. inability to cry, cyanosis, collapse; emergency procedures that can be done if airway obstruction occurs; preventive measures 2. BRONCHITIS - sometimes referred to as tracheobronchitis - inflammation of the large airways (trachea and bronchi), which is frequently associated with an upper respiratory tract infection - characterized by dry, nonproductive cough that worsens at night and becomes productive in 2-3 days - mild, self-limiting disease which requires symptomatic treatment: analgesics, antipyretics, humidity, cough suppressants prior to sleeping - most patients recover in 5 10 days 3. PNEUMONIA - inflammation of the lungs in which the alveoli become filled with exudate and surfactant may be reduced; the affected portion does not receive enough air; breathing is shallow, as a result the bloodstream is denied sufficient oxygen. - may occur as a primary disease or as a complication of another illness -TYPES: - LOBAR PNEUMONIA all or a large segment of one or more pulmonary lobes is involved - BRONCHOPNEUMONIA - begins in the terminal bronchioles which become clogged with mucopurulent exudate to form consolidated patces in nearby lobules; also called LOBULAR PNEUMONIA - INTERSTITIAL PNEUMONIA the inflammatory process is more or less confined within the alveolar walls and the peribronchial and interlobular tissues. VIRAL PNEUMONIA caused by RSV in infants; parainfluenza, influenza, and adenovirus in older children - prognosis is generally good - treatment is symptomatic: measures to promote oxygenation and comfort, chest physiotherapy and postural drainage; antipyretics for fever; fluid intake and family support; antimicrobial therapy - SEVERE ACUTE RESPIRATORY SYNDROME severe form of pneumonia first reported in Asia in 2003 caused by coronavirus manifestations include fever, headache, cough, shortness of breath, difficulty breathing; after 2 7 days, a dry non productive cough and dyspnea nursing care and treatment involve supportive care; symptomatic treatment; airborne isolation precautions

BACTERIAL PNEUMONIA - most commonly caused by Streptococcus pneumoniae ASPIRATION PNEUMONIA - occurs when food, secretions, inert materials, volatile compounds,or liquids enter the lungs and cause inflammation - a hazard in a child who is unable to swallow, absent cough reflex, force-fed, especially while crying or breathing rapidly - care is the same as that of a child with pneumonia from other causes - the major thrust of nursing care is aimed at prevention of aspiration: proper feeding techniques, preventive measures: avoid using talcum powder, keeping solvents away from children LIPOID PNEUMONIA - occurs when a child inhales an oil-based substance into the airway HYPOSTATIC PNEUMONIA - occurs in children who have poor circulation in the lungs and remain in one position too long such as in recovery from anesthesia MANIFESTATIONS: vary with the patient's age, and the causative organism - dry cough which gradually becomes productive - fever as high as 39.5 40o C and may fluctuate widely over a 24 hour period - increased respiratory rate to 40 80 breaths per minute in infants and 30 50 breaths per minute in older children - shallow respirations - chest pain caused by pleural irritation from frequent coughing - sternal retractions - nasal flaring - listlessness, poor appetite, tends to lie on the affected side - increased white blood cell count TREATMENT: depends on the causative organism - antipyretics - oxygen for dyspnea - increased fluid intake - Pediazole (combination of erythromycin ethylsuccinate and sulfisoxazole acetyl) for infants younger than 6 months of age - amoxicillin for children up to 5 years of age - rest, fluids, cough suppressant before bedtime - parent education concerning the need to complete all medication prescribed - preventive measures NURSING CARE: basically the same in all types - must be organized in clustering care - monitor vital signs at regular intervals - administer medication as ordered - parent education for home care 1. INFLUENZA (flu) - an infectious disease caused by the influenza virus (Orthomyxoviridae) influenza virus A,B (cause epidemic diseases) and C (less common and cause mild disease in children) - frequently most severe in infants - during epidemics, infection among school-aged children is believed to be a major source of transmission in a community - affected persons are most infectious for 24 hours before and after the onset of symptoms MANIFESTATIONS: - fever - cough - nasal congestion - body aches - fatigue - headache - watering eyes it can be difficult to distinguish between the common cold and influenza in the early stages of these infections but a flu can be identified by a high fever with a sudden onset and extreme fatigue TREATMENT - antiviral drugs such as oseltamivir (Tamiflu) and zanamivir (Relenza) - symptomatic treatment OTITIS MEDIA inflammation of the middle ear occurs most often after an URTI usually affects children between 6 and 24 months and in early childhood caused by Streptococcus pneumoniae; Haemophilus influenza RISK FACTORS: infants pooling of fluids such as milk in the throat of an infant who falls asleep with a bottle of milk passive smoking environment MANIFESTATIONS: pain in the ear

irritability diminished hearing fever frequent rubbing/pulling of ear rolling of head from side to side older children may point to the tender site visualization with an otoscope reveals reddened bulging membrane TREATMENT: directed towards finding the causative agent and relieving symptoms throat culture broad-spectrum antibiotics analgesics surgical treatment myringotomy comfort measures antipyretics place on affected side if eardrum has ruptured ice pack to reduce edema and pressure skin care CHRONIC OTITIS MEDIA condition persists for more than 3 months

ACUTE PHARYNGITIS inflammation of the pharynx or the throat common among children between 5 15 years of age CAUSATIVE AGENT: 80 % of cases: virus ( adenovirus) 20 % of cases: bacteria ( Group A beta-hemolytic streptococcus) MANIFESTATIONS: fever dysphagia malaise anorexia VIRAL PHARYNGITIS : conjunctivitis, rhinitis, cough, hoarseness, and persisting no STREP PHARYNGITIS: high fever (40oC), dysphagia, and may last longer than 1 week determined by throat culture

longer than 5 days

TREATMENT: prevention of complications nonsuppurative complications: rheumatic fever usually occurs 2 4 weeks after an episode of pharyngitis without antibiotic therapy poststreptococcal glomerulonephritis may develop 1 2 weeks after an untreated throat infection suppurative complications: occur as infection spreads from pharyngeal mucosa to deeper tissues cervical lymphadenitis; peritonsillar or retropharyngeal abscess; sinusitis; mastoiditis; otitis media; miningitis; bacteremia; endocarditis; pneumonia abatement of clinical signs and symptoms reduction of bacterial transmission to close contacts complete the course of antibiotic therapy NURSING RESPONSIBILITIES explain to the parents the need for the child to finish all of the medication cold or warm compresses to the neck may provide relief warm saline gargles offer relief of throat discomfort correct medication administration and completing the course of antibiotic therapy prevent the spread of disease (child is considered noninfectious to others 24 hours after initiation of antibiotic therapy

TONSILLITIS inflammation of the tonsils TONSILS: masses of lymphoid tissue located at the pharyngeal cavity filter and protect the respiratory and tracts from invasion by pathogenic organism generally children have larger tonsils than adolescents or adults palatine tonsils usually visible during oral examination pharyngeal tonsils (adenoids) located above the palatine tonsils on the posterior wall of the nasopharynx lingual tonsils located at the base of the tongue often occurs with pharyngitis causative agent may be viral (adenovirus) or bacterial (Group A streptococcal) MANIFESTATIONS:

severe sore throat ear pain dysphagia/odynophagia headache fever chills tenderness of the jaw and throat characterized by signs of red swollen tonsils which may have a purulent exudative coating of white patches swelling of the eyes, face and neck TREATMENT: VIRAL: self-limiting; symptomatic treatment BACTERIAL: antibiotic therapy with penicillin; erythromycin; clarithromycin TONSILLECTOMY surgical removal of the palatine tonsils done when there is obstruction of airway ADENOIDECTOMY surgical removal of the adenoids recommended for children who have hypertrophied adenoids that obstruct nasal breathing surgery is not usually recommended for children under 3 years of age NURSING RESPONSIBILITIES: provide comfort warm saline gargles, throat lozenges, analgesics, antipyretics prepare child for surgery postoperatively: place child on their abdomen or side suction secretions carefully discourage blowing of nose or clearing of the throat administer analgesics NPO until fully awake and no signs of hemorrhage give soft foods initially on the first postoperative day or as child tolerates feeding do not give milk watch closely for signs of bleeding increased pulse (greater than 120 bpm) pallor frequent clearing of the throat or swallowing and vomiting of bright red blood provide for family support and home care avoiding irritating foods avoiding gargles or vigorous toothbrushing avoid putting objects in the mouth using analgesics for pain limiting activity to decrease the potential for bleeding hemorrhage may occur up to 10 days after surgery as a result of tissue sloughing from the healing process

SINUSITIS - infection of the sinuses near the nose. These infections usually occur after a cold or after an allergic inflammation. There are three types of sinusitis: acute sinusitis - occurs quickly and improves with the appropriate treatment. subacute sinusitis - does not improve with treatment initially, and lasts less than three months. chronic sinusitis - occurs with repeated acute infections or with previous infections that were inadequately treated. The symptoms last longer than three months. - happens after an upper respiratory infection (URI) or common cold. The URI causes inflammation of the nasal passages that can block the opening of the paranasal sinuses, and result in a sinus infection. - Allergies can also lead to sinusitis because of the swelling of the nasal tissue and increased production of mucus. - other possible conditions that can block the normal flow of secretions out of the sinuses: enlarged adenoids abnormalities in the structure of the nose diving and swimming infections from a tooth trauma to the nose foreign objects stuck in the nose cleft palate

- when flow of secretions is blocked, bacteria may begin to grow (Streptococcus pneumoniae; Haemophilus influenzae MANIFESTATIONS: runny nose lasts 7 10 days; discharge usually thick green or yellow swelling around the eyes usually no headache younger than 5 years of age halitosis TREATMENT: 10 14 day course antibiotic therapy ( Amoxicillin) acetaminophen for pain ALLERGIC RHINITIS inflammation of the nasal mucosa caused by an allergic response not life-threatening; does not require hospitalization the mast cells in the nasal mucosa respond to an antigen by releasing mediators such as histamine, which cause edema and increased mucous flow exposure to allergen triggers response MANIFESTATIONS: - nasal congestion - clear, watery nasal discharge - sneezing - itching of the eyes TREATMENT: symptomatic treatment with antihistamine medications prophylactic therapy with cromolyn inhalants (inhibits the release of mediators from mast cells) may be prescribed if antihistamines are not effective NURSING RESPONSIBILITIES: Teach the family about controlling the environmental exposure to allergens